ASSESSMENT AND DIAGNOSIS

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Basil Wilson
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1 ASSESSMENT AND DIAGNOSIS

2 Overview

3 Clinical Features of Central Sensitization/Dysfunctional Pain Pain Pain all over body Muscles stiff/achy Headaches Pain in jaw Pelvic pain Bladder/urination pain Anxiety/depression Sad or depressed Anxiety Stress makes symptoms worse Tension in neck and shoulder Grind/clench teeth Fatigue Do not sleep well Unrefreshed in morning Easily tired with physical activity Other symptoms Difficulty concentrating Need help with daily activities Sensitive to bright lights Skin problems Diarrhea/constipation Mayer TG et al. Pain Pract 2012; 12(4):

4 Central Sensitization Inventory (CSI) A self-report measure designed to assess key somatic and emotional symptoms often associated with central sensitivity syndromes, including fibromyalgia Clinical goal: help better assess symptoms to aid physicians in syndrome categorization, sensitivity, severity, identification, and treatment planning and to help minimize or avoid unnecessary diagnostics and treatment procedures Fibromyalgia patients report high CSI scores Test demonstrates psychometric strength, clinical utility and validity Mayer TG et al. Pain Pract 2012; 12(4):

5 Central Sensitization Inventory (CSI) Part A Part B Mayer TG et al. Pain Pract 2012; 12(4):

6 Diagnosing Fibromyalgia On average it takes patients >2 years to be diagnosed with fibromyalgia A estimated 75% of people with fibromyalgia remain undiagnosed Overview of Diagnosis History of fibromyalgia or related conditions Personal and family history Physical examination Most important to identify any other possible conditions Differential diagnosis Clinical/laboratory evaluation to identify other possible conditions Consequences of Non-diagnosis Failure to diagnose fibromyalgia is associated with increased costs and increased use of medical resources Annemans L et al. Arthritis Rheum 58(3): ; Choy E et al. BMC Health Serv Res 2010; 10:102; Clauw DJ et al. Mayo Clin Proc. 2011; 86(9):907-11; Mease P. J Rheumatol 2005; 32(Suppl 75):6-21; Wolfe F et al. Arthritis Rheum 1990; 33(2):

FiRST: Fibromyalgia Rapid Screening Tool Self-administered 6-item questionnaire Score of 5 is indicative of fibromyalgia Sensitivity: 90.5% Specificity: 85.7% Items 1. I have pain all over my body. 2.

7 FiRST: Fibromyalgia Rapid Screening Tool Self-administered 6-item questionnaire Score of 5 is indicative of fibromyalgia Sensitivity: 90.5% Specificity: 85.7% Items 1. I have pain all over my body. 2. My pain is accompanied by continuous and very unpleasant general fatigue. 3. My pain feels like burns, electric shocks or cramps. 4. My pain is accompanied by other unusual sensations throughout my body, such as pins and needles, tingling or numbness. 5. My pain is accompanied by other health problems such as digestive problems, urinary problems, headaches or restless legs. 6. My pain has a significant impact on my life, particularly on my sleep and my ability to concentrate, making me feel slower generally. Perrot S et al. Pain 2010; 150(2):250-6.

8 History

9 How to Recognize Fibromyalgia: Pain Is the Common Piece of the Puzzle Leg cramps Restless legs Numbness/tingling Fatigue Pain Insomnia Impaired memory/concentration Nervousness Depression Wolfe F et al Arthritis Rheum 1990; 33(2):

Patients with Fibromyalgia Present with a Global Pain Disorder This is a pain drawing Patient colors all areas of the body in which he or she feels pain 1 The diagram shows that the pain of

10 Patients with Fibromyalgia Present with a Global Pain Disorder This is a pain drawing Patient colors all areas of the body in which he or she feels pain 1 The diagram shows that the pain of fibromyalgia is widespread 2 1. Silverman SL, Martin SA. In: Wallace DJ, Clauws DJ (eds.). Fibromyalgia & Other Central Pain Syndromes. Lippincott, Williams & Wilkins; Philadelphia, PA: 2005; 2. Wolfe F et al. Arthritis Rheum 1990; 33(2): Back Front Adapted from pain drawing provided courtesy of L Bateman.

11 Symptoms of Fibromyalgia Pain, fatigue and sleep disturbance are present in at least 86% of patients* % 96% 86% % 60% 56% 52% 46% 42% 41% 32% 20% 0 *United States data Wolfe F et al Arthritis Rheum 1990; 33(2):

Core Clinical Features of Fibromyalgia Widespread pain Chronic, widespread pain Widespread is the

Patient descriptors of pain include: Patient descriptors of pain include: aching, exhausting, nagging,

fibro fog ) Sleep disturbance/fatigue Mood disorders Morning stiffness Carruthers BM et al.

J Rehabil Med 2003; 41(41 Suppl):89-94; Leavitt et al.

12 Core Clinical Features of Fibromyalgia Widespread pain Chronic, widespread pain Widespread is the defining Pain feature of fibromyalgia Chronic, widespread pain is the defining feature of fibromyalgia Patient descriptors of pain include: Patient descriptors of pain include: aching, exhausting, nagging, and hurting Aching Presence of tender points Exhausting Nagging Hurting Neurocognitive impairment ( fibro fog ) Sleep disturbance/fatigue Mood disorders Morning stiffness Carruthers BM et al. J Chron Fat Synd 2003; 11(1):7-115; Harding SM. Am J Med Sci 1998; 315(6):367-37; Henriksson. J Rehabil Med 2003; 41(41 Suppl):89-94; Leavitt et al. Arthritis Rheum 1986; 29(6):775-81; Roizenblatt S et al. Arthritis Rheum 2001; 44(1):222-30; Wolfe F et al Arthritis Rheum 1990; 33(2):160-72; Wolfe F et al. Arthritis Rheum 1995; 38(1):19-28.

13 Stressors Some triggering event may trigger fibromyalgia but is not a prerequisite Onset of fibromyalgia is often gradual, with no identifiable trigger Stressors that may trigger fibromyalgia: Peripheral pain syndromes Physical trauma, Infections (e.g., parvovirus, Epstein-Barr virus, Lyme disease, Q fever) Psychological stress/distress, including sleep disturbances Development of fibromyalgia after a precipitating event may represent the onset of a prolonged and disabling pain syndrome with considerable social and economic implications. Greenfield S et al. Arthritis Rheum 1992; 35(6):678-81; McLean SA, Clauw DJ. Med Hypotheses 2004; 63(4):653-8.

14 Fibromyalgia as a Consequence of Trauma Factors Triggering Fibromyalgia or Associated with its Onset (n = 136) Factor Trigger factors Associated factors* Cold 0 15 Stress 9 35 Emotions 5 35 Overwork 0 22 Trauma Surgery 4 13 Death in the family 0 13 Family problems 2 25 Fatigue 0 23 No cause/association 55 5 In most cases of fibromyalgia, there is no predisposing trigger. *More than one factor possible for the same patient Adapted from: Wolfe F. Am J Med 1986; 81(3A):7-14.

15 Modulating Factors of Fibromyalgia Syndrome Pain Exacerbating factors Mean % Relieving factors Mean % Weather (cold, humidity) 65 Local heat 58 Poor sleep 70 Rest 54 Anxiety, stress 61 Moderate activities 46 Physical inactivity 49 Stretching exercises 43 Noise 22 Massage 40 Yunus MB In: Wallace DJ, Clauw DJ (eds). Fibromyalgia & Other Central Pain Syndromes. Lippincott, Williams & Wilkins; Philadelphia, PA: 2005.

16 Symptom Intensity Scale (SIS) Easy, rapid way to assess regional pain and fatigue in a patient Can uncover comorbid depression Is a simple way to measure overall health Can detect fibromyalgia in patients who have other diseases When fatigue is the dominant system, questionnaire includes consideration of obstructive sleep apnea SIS score is derived from 2 distinct measures: Regional Pain Score Number of anatomic areas (out of 19) in which the patient feels pain + Fatigue Visual Analog Score Patient makes a mark somewhere along a 10-cm line to indicate how tired he or she feels Wilke WS. Cleve Clin J Med 2009; 76(6):

17 Wilke WS. Cleve Clin J Med 2009; 76(6): Symptom Intensity Scale (SIS)

18 Fibromyalgia Impact Questionnaire (FIQ) Developed to capture the total spectrum of problems related to fibromyalgia and responses to therapy Has been shown to have a credible construct validity, reliable retest characteristics, and a good sensitivity in demonstrating therapeutic change Commonly used as an outcome measure in therapeutic trials Self-administered; requires 3 5 minutes to complete Simple directions and scoring Has been translated into 8 languages Most recent version is available at Bennett R. Clin Exp Rheumatol 2005; 23(5 Suppl 39):S

19 Bennett R. Clin Exp Rheumatol 2005; 23(5 Suppl 39):S Fibromyalgia Impact Questionnaire (FIQ)

20 Fibromyalgia Impact Questionnaire (FIQ) For the remaining items, mark the point on the line that beat indicates how you felt overall for the past week. Bennett R. Clin Exp Rheumatol 2005; 23(5 Suppl 39):S

21 Physical Examination

22 Physical Exam: Manual Tender Point Survey Based on 1990 ACR tender point protocol for fibromyalgia Can be performed in 5 10 minutes 18 survey and 3 control sites examined in a specific numerical order Control sites reveal baseline of patient's pain perception ACR = American College of Rheumatology National Fibromyalgia Association. The Manual Tender Point Survey. Available at: Accessed: August 13, 2013

23 Performing a Manual Tender Point Survey Digital palpation with an approximate force of 4 kg Estimated pressure needed to turn the examiner s thumbnail white upon depressing For a positive tender point, subject must state palpation was painful Accuracy for fibromyalgia: Sensitivity: 88.4% Specificity: 81.1% Controversies regarding tender point evaluation: Subjective May not be necessary for diagnostic studies What about fewer than 11 of 18 tender points? National Fibromyalgia Association. The Manual Tender Point Survey. Available at Accessed August 13, 2013; Wilke WS. Cleve Clin J Med 2009; 76(6):345-52; Wolfe F et al. Arthritis Rheum 1990; 33(2):

24 Manual Tender Point Survey: Illustration of 18 Tender Points Lateral epicondyle (2) 2 cm distal to epicondyles Occiput (2) at suboccipital muscle insertions Low cervical (2) at anterior aspects of the intertransverse spaces at C5-C7 Trapezius (2) at midpoint of upper border Supraspinatus (2) at origins, above scapula spine near medial border Second rib (2) upper lateral to second costochondral junction Gluteal (2) in upper outer quadrants of buttocks in anterior fold of muscle Greater trochanter (2) posterior to trochanteric prominence Knee (2) at medial fat pad proximal to joint line Wolfe F et al. Arthritis Rheum 1990; 33(2):

25 Imaging and Other Tests

26 Imaging and Laboratory Tests: Fibromyalgia No specific tests are necessary to diagnosis fibromyalgia, but may be useful to exclude other diagnoses American College of Rheumatology. Fibromyalgia. Available at: Accessed: September 9, 2013.

27 Differential Diagnosis of Fibromyalgia Hypothyroidism Vitamin D deficiency Inflammatory rheumatic disease Cancer Inflammatory muscle diseases Rahman A et al. BMJ 2014; 348:g1224.

28 Differential Diagnoses for Fibromyalgia and Corresponding Testing Options Differential diagnoses Adrenal dysfunction Anemia Bone marrow disease Chronic fatigue syndrome Functional disorders (e.g., intestinal dysbiosis, subtle endocrine imbalances, and postviral immune suppression) Hypothyroidism Lyme disease Psychiatric conditions (e.g., post-traumatic stress disorder, anxiety, and depression) Diagnostic testing options Morning serum cortisol, urinary catecholamine metabolites CBC with differential, RBC indices (MCV, MCH, MCHC) WBC differential, ESR, CRP, CMP Clinical history Standard laboratory testing yields unclear results Thyroid function tests (T3, T4, TSH) Lyme titer, CMP Refer to DSM CBC = complete blood count; CMP = common myeloid progenitor; CRP = C-reactive protein; DSM = Diagnostic and Statistical Manual of Mental Disorders; ESR = erythrocyte sedimentation rate; MCH = mean corpuscular hemoglobin; MCHC = mean corpuscular hemoglobin concentration; MCV = mean corpuscular volume; RBC = red blood cell; TSH = thyroid-stimulating hormone; WBC = white blood cell Bellato E et al. Pain Res Treat 2012; 2012:

29 Differential Diagnoses for Fibromyalgia and Corresponding Testing Options (cont d) Differential Diagnoses Multiple sclerosis Phenomenological referred myofascial pain Rheumatoid autoimmune disorders (e.g., rheumatoid arthritis, ankylosing spondylitis, scleroderma) Sleep disorders Spinal facet pain or sacroiliac joint pain Spinal disc herniation Systemic inflammation or infection Vitamin and/or mineral deficiency Diagnostic Testing Options MRI scan, lumbar puncture, evoked potential testing Muscular tender points on physical examination Rheumatic profile (rheumatoid factor, ESR/CRP), ANA EEG sleep studies Radiologic studies (MRI scan, CT scan), bone scans (minimal diagnostic assistance) MRI scan Radiologic studies (MRI scan, CT scan), bone scans (minimal diagnostic assistance) Radiologic studies (MRI scan, CT scan), bone scans (minimal diagnostic assistance) ANA = antinuclear antibody; CRP = C-reactive protein; CT = computed tomography; EEG = electroencephalography ESR = erythrocyte sedimentation rate; MRI = magnetic resonance imaging Bellato E et al. Pain Res Treat 2012; 2012:

30 Diagnosis

31 Is it fibromyalgia or chronic fatigue syndrome? Fibromyalgia Primary symptom is generalized muscle pain Primary sign is pain at more than 11 of 18 tender points 20 70% meet criteria for chronic fatigue syndrome 1 Chronic Fatigue Syndrome Primary symptom is post-exertional malaise, fatigue No current diagnostic test but mitochondrial dysfunction is suspected Score of <50 on SF-36 physical function scale can help differentiate from major depression 75% also meet criteria for fibromyalgia 2 1. Aaron LA et al. Arch Intern Med 2000; 160(2):221-7; 2. Goldenberg DL et al. Arthritis Rheum 1990; 33(3):381-7.

ACR criteria: ACR Classification Criteria for Fibromyalgia (1990) History of chronic widespread pain 3 months Patients must exhibit 11 of 18 tender

32 ACR criteria: ACR Classification Criteria for Fibromyalgia (1990) History of chronic widespread pain 3 months Patients must exhibit 11 of 18 tender points ACR criteria are both sensitive (88.4%) and specific (81.1%) ACR = American College of Rheumatology Wolfe F et al. Arthritis Rheum 1990; 33(2):

33 ACR Proposed Diagnostic Criteria for Fibromyalgia (2010) Fibromyalgia can be diagnosed if: Patient experiences widespread pain and associated symptoms Symptoms have been present at same level for 3 months No other condition otherwise explains the pain Associated symptoms include: Unrefreshed sleep Cognitive symptoms Fatigue Other somatic symptoms ACR = American College of Rheumatology Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

34 ACR Diagnostic Criteria for Fibromyalgia 2010 The 2010 ACR criteria require assessment of 3 key elements: Presentation of widespread pain and symptoms for 3 months Widespread Pain Index (WPI)* Assesses number of painful body areas Symptom Severity Scale (SSS)* Assesses severity of fatigue, waking unrefreshed, cognitive symptoms, and extent of other somatic symptoms *Health care practitioner-administered questionnaire ACR = American College of Rheumatology Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

35 Widespread Pain Index (WPI) Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

36 Symptom Severity Scale (SSS) (Part A) Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

37 Symptom Severity Scale Other Somatic Symptoms (Part B) Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

38 What the Patient s Scores Mean WPI = widespread Pain Index; SS = Symptom Severity Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

39 Example of Patient Self-report Survey for the Assessment of Fibromyalgia The possible score ranges from 0 to 31 points; a score 13 points is consistent with a diagnosis of fibromyalgia. Wolfe F et al. J Rheumatol 2011; 38(6):

40 Tips on Providing the Diagnosis of Fibromyalgia Be specific about the diagnosis Be positive about the diagnosis Promote and encourage patient self-efficacy around the disease but... Set realistic expectations Emphasize there is no cure but improved control of symptoms is usually possible Arnold LM et al. Mayo Clin Proc 2012; 87(5):

41 Diagnosis of Fibromyalgia Can Improve Patient Satisfaction I M P R O V E M E N T *Statistically significant vs. baseline (confidence interval -1.2 to -0.4) White KP et al. Arthritis Rheum 2002; 47(3):260-5.

42 Summary

43 Assessment and Diagnosis: Summary Key clinical features of central sensitization/dysfunctional pain syndromes are pain, anxiety/depression and fatigue The cardinal symptoms of fibromyalgia are widespread pain, fatigue, sleep disturbance, and cognitive slowing Diagnosis of fibromyalgia is based on widespread pain and associated symptom cluster, with a physical exam (and possible laboratory investigations) to exclude other conditions A number of questionnaires are available for use in assessing patients A diagnosis of fibromyalgia can improve health outcomes and reduce costs

FIBROMYALGIA. Howard L. Feinberg, D.O. F.A.C.O.I., F.A.C.R. OPSC San Diego 2017

FIBROMYALGIA. Howard L. Feinberg, D.O. F.A.C.O.I., F.A.C.R. OPSC San Diego 2017 FIBROMYALGIA Howard L. Feinberg, D.O. F.A.C.O.I., F.A.C.R. OPSC San Diego 2017 Sir William Osler When a patient with arthritis comes in the front door, I try to go out the back door. FEINBERG S COROLLARY